Office of the Fire Commissioner
APPLIANCE GENERAL CHECK LIST
The following general requirements must be met in order to be considered for a field start-up of an appliance
by Inspection and Technical Services Manitoba (ITSM).
***Please note that ALL requirements set forth in CSA B149.1, B149.2, B149.3, Manitoba Acts, Regulations,
Manufacturer’s Instructions, and any additional applicable Codes or Standards not included on this checklist
must be upheld.***
All sections of this form must be completed and signed by a certified Gas Fitter and submitted to ITSM for
review and approval prior to starting up the appliance on-site.
In the case of Construction Heaters, this form must be submitted within 72 hours of start-up.
All appliances that are given approval to start-up based on the content of this form are still subject to field
inspection of an ITSM inspector.
INSTALLER’S INFORMATION
Date (mm/dd/yy)
Fitters Name
Phone Number
Gas Licence Number
Employer
Supervisor’s Name and Contact Number
Employer’s Address
APPLIANCE IDENTIFICATION
Appliance Location (include location and
address)
Make
Model Number
Serial Number
Industry Standard Serial Number (if
applicable)
CH Permit Number (if applicable)
Gas Permit Number (if applicable)
Firing Rate
SAFETY CHECKS
A – SAFETY CHECKS – Permits:
1. Tanks Set Permit
2. Appliance Gas/Oil Permit Obtained from ITSM
3. Appliance Electrical Permit Obtained from ITSM
4. Tank Material and CRN Number (U-1A Form)
YES
NO
N/A
B – SAFETY CHECKS – Certifications:
1. Appliance and all associated components are certified/approved by a recognized
certifying agency (ie: CSA and/or ITSM)
2. Hose is certified/approved by ITSM and is labelled in accordance with Section 6.17
3. Isolation valves certified/approved by ITSM
4. All manufacturer instructions/installation/service manuals are provided iaw CSA
149.2; 3.3.3
5. The Gas Fitter has instructed the user in the safe and correct operation iaw CSA
149.2; 4.3.2
6. All components conform to appropriate use
7. All containers are CSA certified and registered for use in Manitoba
8. All manufacturer labels are legible and intact
YES
NO
N/A
C – SAFETY CHECKS – Manufacturer Requirements:
1. Appliances are installed level (multiple appliance are level to each other)
2. Appliance supports have been installed and are in good condition (factory supplied)
3. Appliances are installed on a firm, level, non-combustible material (ie: concrete
pad) in accordance with manufacturer instructions, and in a manner that will not
allow tipping
YES
NO
N/A
D – SAFETY CHECKS – CSA B149.1 Installation Requirements:
1. Protection installed where physical damage can be incurred (4.23)
2. All service clearances are in accordance with manufacturer’s instructions and CSA
B149.1
3. Piping must comply with ASTM A 53/A 53M or ASTM A 106 and shall be at least
schedule 40 or Schedule 80 in accordance with Section 6.2.3
4. Underground piping, tubing or fittings are protected from damage (trench properly
graded, fill material free from sharp objects, etc.) complies with Section 6.15 and
are protected against corrosion in accordance with 6.16
5. Pressure test performed in accordance with 6.22.2
6. Venting is free from hazards (away from electrical, containers, appliance air intakes,
etc.) and is vented to atmosphere
7. Floor plane (secure)
8. All vapour relief valves function correctly and are rated for 250 PSIg
9. Excess flow valve and correct size of downstream piping
10. Tank manual isolation valve(s) (ratings and pressures checked in relation to
hydrostatics)
11. Flare fittings (forged)
12. Hydrostatics certified and installed in all locations where propane may be isolated
13. Hydrostatics at correct pressures (dryer and main gas line)
14. Valves for multiple systems (branch lines)
15. Piping at valves secured
16. Regulators are correctly installed, in the proper position, and are adequately
supported
17. Piping allows for movement, expansion and contraction
18. Appliance leak tested (SSOV’s leak tested)
19. Appliance SSOV’s certified and marked, correct pressure for liquid and/or vapour
side
YES
NO
N/A
D – SAFETY CHECKS – CSA B149.1 Installation Requirements:
20. All containers are in an upright position
21. Any potential hazards have been eliminated
YES
NO
N/A
Comments Check List (Please quote number)
A. PERMITS:
B. CERTIFICATION:
C. MANUFACTURER REQUIREMENTS:
D. CSA B149.1 INSTALLATION REQUIREMENTS:
I certify that the above information is true and correct and complies with Manitoba Regulation 104/87R
Name of Gas Fitter
Signature of Gas Fitter
Licence Number
Date
Creation Date: October 18, 2012
Please submit a signed copy of the Appliance General Check List by one of the following three methods:
Mail:
The Office of the Fire Commissioner
Inspection and Technical Services Manitoba
500 – 401 York Avenue, Winnipeg MB R3C 0P8
Fax:
204.948.2309
Email:
firecomm@gov.mb.ca